Residential Structural Racism and Prevalence of Chronic Health Conditions

Key Points Question Are indicators of residential neighborhood (census block group) structural racism associated with the prevalence of chronic health conditions? Findings In this cross-sectional study of 150 neighborhoods in Durham County, North Carolina, an increased burden of structural racism indicators, including global (lower percentage of White individuals, lower economic and racial spatial advantage, and higher area deprivation) and discrete (higher reported violent crimes, evictions, poverty, unemployment, uninsurance, and child care center density, and lower election participation, income, and education) measures were associated with greater neighborhood prevalence of chronic kidney disease, diabetes, and hypertension. Meaning These findings suggest that structural racism indicators should be considered when developing interventions to improve neighborhood health.

paramount issue so all metrics in the community compass were aggregated at the level of block groups, and these data were masked if there were less than 3 individuals in a block group in our effort to protect patient privacy.Each chronic condition noted below was determined based on lab values/health encounters for patients in the calendar year specified 23 , who also had a recorded Durham County physical home address or post office box.If patients were hospitalized across multiple days across several calendar years, the discharge date was used to determine whether they would be included within that end-date calendar year.Using the EHR data and input from subspecialty experts, we defined the following conditions: Chronic kidney disease Counts of adults with Kidney Disease Improving Global Outcomes (KDIGO)-defined CKD III-V were ascertained based on lab values and health encounters in 2017 23 .We considered individuals as having CKD III-V if they had at least 2 eGFR measurements less than 30 ml/min/1.73m 2 (by CKD-EPI) 96,97 at least 90 days apart, or one GFR less than 30 and one albumin to creatinine ratio greater than or equal to 30 mg/g.We did not exclude individuals receiving any form of kidney replacement therapy (i.e., hemodialysis or peritoneal dialysis) or kidney transplant as these data were not available.Notably, our analyses included eGFR as calculated with the Black race modifier because of the timing of the National Kidney Foundation-American Society of Nephrology 98 joint taskforce recommendation for removal of the race modifier, which did not go into effect at Duke until June 2021 [98][99][100] .We categorized neighborhood prevalence of each chronic disease into tertiles.

Diabetes
The number of adult residents with diabetes (DM) was assessed in 2017.DM was defined as any individual who had type II diabetes according to either ICD codes 249, 250, Eo8, E09, E11, or E13 or based on a hemoglobin A1C (HbA1C) measurement of 6.4% or above.
Hypertension The total number of individuals with hypertension (HTN) in each block group was ascertained in 2018.HTN was defined as any individual who had a systolic blood pressure >140 mmHg or diastolic blood pressure > 90 mmHg within a 12-month period excluding inpatient readings and/or an ICD 9 code of 401/405, and ICD 10 codes of I10, or I15.This categorization excluded HTN in pregnancy.We did not have data collected and reported on the Compass regarding the HTN data in 2017, thus the first time point of availability of this data was in 2017.We carefully considered the many domains through which structural racism operates, which are described below, along with our considerations for each variable used.

BUILT ENVIRONMENT Impervious areas (Durham Compass)
The built environment was characterized using a 2016 measure of impervious areas, an Environmental Protection Agency variable intended to capture the percent of a region where groundwater is unable to drain because of artificial structures and pavement.Greater percentages of impervious land area may occur in areas manifesting greater structural racism.Furthermore, more impervious areas may cause environmental harm and poor health outcomes via impaired water quality (pollutant accumulation may be then washed into streams), disregulated water quantity (impervious areas prevent natural groundwater accumulation and favors storm drainage accumulation, which may cause flooding etc.), and via temperature (rainwater in impervious areas may become extremely heated, thus disrupting the natural ecosystems of the streams into which they drain).

HOUSING Eviction rates (Eviction Lab)
Evictions were measured in 2017-2018 by determining the number of homes that received an eviction judgment in which renters were ordered to leave.This value counts only single addresses (and nor all persons) that received this judgment over a denominator of the number of occupied renting households in each area.Information on the number of renter homes in an area comes from the U.S. Census and ESRI Business analyst demographic estimates.
Eviction rates have been described as a key driver of health outcomes because of the legal consequences of having had an eviction including subsequent exposure to a higher risk rental market, increased risks of homelessness/housing insecurity, and interrupted health care engagement if physical distance and transportation is a barrier. 108,109Several prior studies have described the disproportionate impact of evictions on racially and ethnically minoritized groups across multiple cities, a disadvantage that may be influenced by individual level and neighborhood level and social network level features. 108When numerous evictions are concentrated in a specific neighborhood, individuals living within that area may be adversely impacted because of this state of instability, which does not guarantee afforded privileges of wealthy individuals.This may also diminish civic empowerment and policy changes that are health promoting for those who are displaced.Evictions have also been described as a proxy for gentrification-led displacement of individuals. 110

POLICING CRIMINALIZATION AND SAFETY Violent crime reporting (Durham Compass)
Violent crime reporting was assessed in 2016 and described as the number of incidents per square mile, as reported to the Durham Police department by callers.
The excess criminalization of Black and other minoritized people has been described over decades of research and results from a complex amalgam of structural and interpersonal racism, which impact the adjudication of incidents.The downstream impact of this disproportionate penalization has had numerous impacts including by restricting job access and associated health benefits, access to public housing in some cases, access to foods stamps and other benefits, licenses/work permits, financial support for higher education, and voting rights in many states, even after a conviction is served. 111Communities with greater exposure to violent crime reporting are more likely to live in structurally disadvantaged neighborhoods, with downstream impacts on a range of health outcomes.Individuals exposed to greater violent crime reporting may have increased vulnerability to accidental violence/mortality, greater perceptions of danger, less perceptions of safety necessary to engage in health-promoting behaviors like physical exercise, and less perceived social capital. 112Increased allostatic load or increased stress, anxiety, depression associated with living in this type of environment may also be a mediating factor in this relationship between health and violent crime reporting. 113olice shooting (Mapping Police Violence Database) Police shootings (including those of on duty police officers, incidents when a person is killed via use of a chokehold, baton, taser or other means, as well as killings by off-duty police) were assessed from 2013-2018 using data from mappingpoliceviolence.org and we identified neighborhoods in which a shooting occurred using block group FIPS codes mapped onto the locations identified within this data source.The disproportionate criminalization of Black and other minoritized individuals by state sanctioned policies has been described long before the murder of George Floyd.[114][115][116][117][118] Racially minoritized individuals in the U.S.-especially Black individuals-have long experienced disproportionate exposure to police violence and fatal police shootings, which are a public health emergency.47,72,115,116,119 The impacts of this harm include years of life lost, morbidity in terms of anxiety and severe mental health consequences.116

POLITICAL ENGAGEMENT Primary election voting among active voters (Durham Compass)
Primary election participation was assessed in 2012 as the proportion of active voters who voted in the primary election that year using data from the Durham County Board of Elections.Social capital has been defined as a critical feature of social structures "and [includes] interpersonal trust and norms of reciprocity and mutual aid, which act as resources for individuals and facilitate social action." 120Associations between social capital and political activities like voting are well described and demonstrate how geographic variations in voter turnout has been linked to civic trust and social capital, as defined above.Furthermore, voter participation and engagement is influenced by racism and other social forces via 1) voter disenfranchisement of disproportionate segments of the population who have been incarcerated or subject to a biased criminal justice system 121,122 and 2) new challenges posed to voting related to access (e.g., time off of work, discrimination-based distrust of the system). 121,123Poor health and lower voting rates have been associated in many studies without a clear explanation of which is a preceding factor.Individuals with poorer health have often a worse sense of political efficacy, concerns regarding voting accessibility (including in time), and competing social and financial burdens. 124Notably, this data was only available for 2012 and then recollected in 2020 in Durham County; these 2012 data may introduce bias due to over and under reporting of election participation in certain communities in which population demographics shifted voting participation.However, to our knowledge, this is one of the only available data sets which has allowed linkage of local voter participation data in the primary election with health outcomes.

EDUCATION Percent with bachelor's degree (American Community Survey)
The total number of residents aged 25 years or older who attained a bachelor's degree was ascertained in 2017 and 2018.Racial and ethnic disparities in educational opportunities have increased because of segregation, and racial inequities have been exacerbated by interpersonal bias and the inequitable distribution of resources to schools based in residential racial segregation and associated distribution of tax bases/wealth. 125Despite interventions, disparities in what has been called "the most consequential attainment outcomeearning a postsecondary degree" have remained stagnant, reflecting the persistence of structural racism. 125Lower educational attainment has been associated with chronic diseases including CKD, DM, and HTN due to lower health care access, less access to health-promoting interventions, and wealth.

Childcare Centers (Durham Compass)
The measure of childcare centers and family child-care homes licensed by the state of North Carolina's Division of Child Care and Early development from 2017-2018 per square mile (which does not include unlicensed locations).Access to child-care in early-child development has significant implications for families and long-term health outcomes.Structural racism impacts the availability and location of high-quality child-care centers, and studies have demonstrated that Black and Latino/a/e/Hispanic children are more likely to experience lower quality childcare.However, data regarding the quality of these centers is unavailable in our available data.Out of home childcare has been associated with greater family-level social and economic disadvantage 126 , and other studies have suggested racially/ethnically minoritized Black and Latino/Hispanic children are more likely to be in Head Start versus White counterparts, who may have access to other early education opportunities. 127In addition, child care center quality has been described as lower in more socially disadvantaged neighborhoods. 128Finally, neighborhoods with greater spatial density of child care centers per square mile have been associated with higher rates of early child maltreatment referrals, suggesting need for greater contextualization of the settings in which high densities of lower quality centers occur. 129

UNEMPLOYMENT Percent unemployed (American Community Survey)
Unemployment was ascertained by determining the total number of residents aged 16 years or older in the civilian labor force but who were unemployed in 2017 and 2018 as a proportion of the total number of residents aged 16 years or older in the civilian labor force.Unemployment may reflect discriminatory hiring practices, which have not equitably distributed opportunity between minoritized vs. White individuals, which impacts health insurance and other critical resource access. 130,131Unemployment has also been associated with poor health outcomes, including CKD, DM, and HTN.

HEALTH CARE INSURANCE COVERAGE Percent uninsured (American Community Survey)
Uninsurance was ascertained by determining the total number of individuals without any health insurance in 2017 and 2018, as a proportion of total adults.Lack of insurance may reflect a manifestation of structurally inequitable policies which have eliminated opportunities for nonemployer-based health insurance and other mechanisms that provide universal coverage (e.g., Medicaid expansion). 132,133Uninsurance has been associated with higher prevalence of CKD, DM, and HTN and poorer outcomes among individuals with a range of chronic health conditions.

COMPOSITE MEASURES OF STRUCTURAL RACISM Percent Whiteness (American Community Survey)
The percent of the White population was ascertained for each census block group using data from 2017-2018.Block groups with a higher percentage of individuals racialized as White receive structural advantages including resources and health-impacting opportunities.This greater accrual of advantaging resources (versus neighborhoods with a lower % of the population racialized as White) is associated with lower chronic disease prevalence.

Area deprivation index (ADI)
ADI was ascertained in 2015 through linkage of neighborhoods to the publicly available ADI state rankings in deciles 62 , in which a higher decile corresponds to more deprivation.The area deprivation index integrates key values from 18 Census variables including poverty, education, housing, and unemployment to characterize the level of deprivation in a certain region, and has been used to aid with targeted resource allocation and associated with numerous health outcomes including all-cause mortality, cervical cancer, and Alzheimer's disease. 62Index of Concentrations at the Extremes (ICE) (race-income) ICE race-income was calculated using data from 2016-2017.ICE is the ratio of the difference between extremely "advantaged" and extremely "disadvantaged" units (e.g., individuals or households) to the total number of units in the region of interest, where the definitions of "advantaged" and "disadvantaged" depend on the construct of interest.For example, if the measure is income, then those in the 80th percentile and 20th percentile might represent advantaged and disadvantaged groups, respectively.Similarly, if the measure is race, White and Black might be the comparison groups.Following the methodology developed by Krieger et al, the combination ICE for race and income used in this study compared households with a White householder and income ≥$100,000 to those with a Black householder and income <$20,000.The ICE-RI was calculated at the census tract level due to income data by householder race being unavailable at the block group level.This may limit the accuracy of the extrapolation of this data to the BG level.We further identified structural racism via the spatial and racial/economic polarization of communities across neighborhoods due to redlining and other structurally racist policies, which created and sustained spatial polarization of neighborhoods.Racialized economic segregation operationalized by ICE-race income measures have been associated with a range of negative health outcomes in multiple studies and has been used a proxy for structurally racist policies that concentrated wealth/advantage in primarily White neighborhoods. 46,597][78][79][80][81][82][83][84][85] Because structural racism has a differential effect on individuals according to their racialization as White or as a minoritized person (i.e., less effects on White individuals versus racially minoritized individuals), 50-54 we sought to describe various socio-structural features of each neighborhood as categorized by the % of White individuals of each neighborhood. 53,55We also examined the association between measures that discretely describe manifestations of structural racism and ICE-race-income on health outcomes.For instance, the Index of Concentration at the Extremes has been used to measure spatial polarization of deprived and socially privileged groups (by race and income), and has been used as a proxy for structural racism in association with pre-term birth, infant mortality 8,9,59 While there are nuances in the experiences of individuals racialized as White and as racial and ethnic minorities across race and ethnicity, the accumulation of privilege over generations/time is a unique feature for individuals racialized as White, as is the aggregation of these resources in areas in which a greater percentage of White individuals reside.

Table 1a
Census block group characteristics stratified by tertiles of ICE race-income in 2017 (not age adjusted).Values given are median [IQR] except police shootings which is n (%).* ICE-RI is not reverse coded in this table Census block group characteristics stratified by tertiles of Area Deprivation Index in 2017 (not age adjusted).Values given are median [IQR] except police shootings which is n (%).

Indicators of structural racism
Po104,106,107 were determined from the Eviction Lab in 2016 using 2014-2018 5-Year American Community Survey estimates.Communities with a greater proportion of minoritized individuals are characterized by greater poverty due to structural disadvantage and structural racism.Poverty has been associated with greater prevalence of CKD, DM, and HTN.3,104,106,107 104,105ousehold proximity to bus stops (Durham Compass) We assessed access to public transport options through a measure of proximity to bus stops determined by Go Triangle transit and city-council GIS in 2017.Access was defined as residential units within ¼ mile Euclidean distance to a bus stop.Lower transportation access has been associated with increased barriers to health care access.102However, greatepublic transit access may be located in more minoritized/marginalized communities in certain contexts, including in Durham County wherein a greater proportion of White individuals are car owners.Tree coverage (Durham Compass)This measure of tree coverage was ascertained from the National Agricultural Imagery Program (NAIP) data sourced in 2016 from the EPA EnviroAtlas for urbanized parts of Durham County.Greater tree canopy has been associated with communities characterized by greater sociopolitical advantage.Greater tree coverage has also been associated with multiple improved health outcomes, mediated by greater physical activity and social cohesion.103ECONOMICSMedianhouseholdincome(Durham Compass)The median household income of the neighborhood in dollars was assessed in 2017-2018, and represent a marker of economic stability, which are impacted by structural racism and associated policies.Lower median household income has been associated with greater prevalence of CKD, DM, and HTN.104,105Poverty rates (Eviction Lab)